Breaking Bad News for Patients with Gastro-Intestinal Malignancy: Experience at Ibn Sina Teaching Hospital

Integrity, beneficence, non-maleficence and Justice are the pillars of the professional behaviour. Confidentiality is a serious issue governed by the law. However, in developing countries, patients' relatives urge to know the diagnosis and often request the doctor not to mention the word cancer or malignancy to their patient. To evaluate the communication skills for breaking bad news to Sudanese patients suffering of gastrointestinal cancer and to find out the patients' responses on that matter. This is a hospital based non-randomized prospective study, carried out at Ibn Sina Specialized Hospital in the period August through December 2011. The study involved113 patients of whom there were 56 males. Doctors had talked about the disease to 75% of the patients whereas the rest were told by either the psychologists and/or their relatives. Only 25% of the patients were told the truth, the rest were told to have mass or lump without explaining its nature. Patients' responses were as follows: 41.6% were felt terrified, 23.9% were shocked and became anxious, while 33.6% were stable, but 0.9% became angry and frustrated. No patient was told about the prognosis and the chances of cure. Sympathy over-ride empathy in communicating bad news to Sudanese patients suffering of cancer. Patient education and training in breaking the bad news is needed

Testicular embryonic rhabdomyosarcoma, case report with brief literature review

Rhabdomyosarcoma [RMS] is a malignant solid tumour arising from mesenchymal tissues which normally differentiate to form striated muscle. It can occur in a wide variety of sites. It is one of the most frequently occurring soft tissue sarcomas and commonest in children under age of 15 years 1. Approximately 350 new cases are diagnosed in the United States each year 2. Seven to 10% of primary genitourinary tumours are located in the para-testicular region. Scrotal rhabdomyosarcomas originating from paratesticular tissue are most frequently seen in childhood and young adults 3. Paratesticular rhabdo-myosarcomas are very rare, comprising only 1: 2,000 tumours of the male genital system 4. It constitutes 7% of all rhabdomysarcomas 5. The disease may be subdivided into embryonal [which accounts for about 60%], pleomorphic, alveolar and botryoidal types. Embryonal RMS is most commonly found in head and neck, genitourinary and retroperitoneal sites 6. The tumour is slightly more common in boys and males [11.8 per million] than in girls and females [10.3 per million]2. The age incidence varies from 21 months [Sabrazes et al, 1923] to 67 years [Prince, 1942]3. However, some had reported racial and gender differences in the incidence of RMS7. Here we report an adult male of paratesticular embryonal RMS. He was lost trace for a while till he present with advanced metastases to the retroperitonium and a multidisciplinary management was held later

Intra-abdominal lymphangioma with ascriasis as diagnostic predicament

Lymphangiomas are rare tumours. About 90% of lymphangiomas manifest in children at the age of three years1. The sex ratio is roughly equal in childhood2. In young patients lymphangiomas are preferentially located in head, neck and axilla, but they also occur sporadically in various parenchymal organs e.g. spleen, liver and bones. When it is diffuse as multifocal disease [lymphangiomatosis] during adulthood, it develops as superficial cutaneous lymphangioma or as intra-abdominal lymphangiomas. The male to female ratio for intra-abdominal lymphangiomas3 is 3:1. Here we present a case of intra-abdominal lymphangioma in a 14-year old boy who presented as a diagnostic dilemma

Perception of professionalism among first year medical students in OIU

Since days of Hippocrates, and passing through the Geneva Declaration and Helsinki Convention the eve of the 21st century guidelines and mission statements dominated the medical education and practice. Giving and receiving feedback are critical skills and should be taught early in the process of medical education, yet few studies discuss the effect of feedback curricula for first year medical students. To evaluate the concepts of professionalism among the first year medical students. The Faculty of Medicine and Health Sciences, Omdurman Islamic University where students are taught. The first year medical students at the Faculty of Medicine and Health Sciences, Omdurman Islamic University were taught the Human Rights declaration issued by the United Nations in Dec 1948, The Principals of Islamic Human Rights, basics of medical ethics and

the Doctors Figh and University Requirement course of Islamic studies. A pretested questionnaire, self -administered questionnaire with five Likert scale was distributed. The total number of the first year medical students was 257 but 207[80.5%] successfully completed the questionnaire. A total of 98% strongly agreed that the doctor must be truthful. 90% of the students and agreed that the doctor must be caring, kind and empathetic, respect the others, skilful, dedicated and Also, should comply with the patients' needs [One sample t-test 2-tailed P =0.0001]. However, 23[13.8%] students disagree on the role of the doctor as an advocate for the patient. The students strongly agreed for the importance of working as a team and sparing the patient not to be harmed had any conflict raised [one sample t-test 2-tailed P = 0.0001]. The first year medical students seem to have benefited of the Human Rights declaration issued by the United Nations in Dec 1948, The Principals of Islamic Human Rights, basics of medical ethics and the Doctors Fight and university requirement course of Islamic studies. About 9[5.4%] -24[12.4%] are not clear about the role of the medical professional in the society in advocating for patients

Trends of gastric malignancies: Case study of Ibn Sina Hospital 2010-2011

Gastric malignancies carry poor prognosis, because they commonly present at an advanced stage. To find out mode of presentation and its impact on the outcome and management of gastric cancer and to find if there are changes in trends of gastric malignancies over the last decade. A review of 53 patients with gastric malignancies, treated at Ibn Sina Hospital from August 2010 through August 2011. Their demographic data, pattern of clinical presentation, histopathology grading and staging, type of management and hospital mortality were studied. Statistical analysis: Data was fed to Statistical Package for Social Sciences. Means and correlations were computed where appropriate. One sample t-test was performed. Statistical significance was taken at P = 0.05. Out of 53 patients males comprise 30[56.6%] males. The peak frequency was at the age group 55-70 years. Patients from the Northern Region of Sudan constituted 34%. Adenocarcinoma comprised 43[81.3%], GIST 8[15%], lymphoma 1[1.9%] and carcinoid 1[1.9%]. Epigastric pain was the commonest symptom in 47[88.7%] patients. Smoking and snuff [Tombak] and high salt diet were found in 7.5% and 5.7% and 3.8% patients respectively. Blood group A and O was found in 22.6% and 60.4% respectively. Family cancer syndrome was found in 11.3% patients. Malignancies of the antrum constitute 27[65.85%], cardia 4[9.8%], body 7[17.1%], and whole stomach 3[7.3%] patients. There were only 6.25% clinically early cases. Potentially curative resection was attempted in 31.7%. The mean hospital stay was 12 days. Patients presented at stage III and IV comprise 30 [93.75%] out of 32 carcinoma patients. The hospital morbidity was 13[24.6%] patients and mortality 4[7.5%] patients. When compared with results from same hospital there is improvement in outcome over a decade

Prospective randomised controlled trial of teaching medical students behavioural sciences

In the last few decades, medical professionalismcame upas a challenging issue to teach and assess. To compare the level of understanding of the medical professionalism, medical ethics and human rights among the first year and fifth year medical students at Omdurman Islamic University in Sudan. Prospective randomised controlled trial. Students were randomized in to four groups during teaching of behavioural sciences which was given at different spectra in the different groups. Responders were 365[91.25%], they were 143[39.2%] first year males, 141[38.6%] first year females split in two groups and 81[22.2%] fifth year mixed male and female.Conceptual understanding of medical ethics, professionalism, human rights and the religion values as part of the university requirement were assessed with a pretested questionnaire. Of the fifth year students 69[86.3%] were able to describe triggering organisational help for patients as an advocacy and 119[83.2%] first year male students were able to identify that availing medical facilities to the disabled and the vulnerable groupsas basic human right. The majority [>90%] of all students were described well professional integrity and 132[93%] of first year medical students were able mention correctly the differences between the Healer and the professional and 83[58.5%] of fifth year students specified the confidentiality issue in taking informed consent, respectively. However, the students' categorised the regulation of organ transplantation and tissue engineering has human rights followed by Religion Teachings bases. Teaching medical ethics, human rights, professionalism and University requirements to the first year medical students and gains during the practical experience of the clinical clerkship have a considerable impact on the student perception of these subjects. Gains are expected to improve if these issues are integrated in all areas of the curriculum

Preliminary report on the Neurology workload ina central hospital in Sudan

Identification of the local pattern of neurological diseases is expected to help setting the priorities for good planning of management and public education. To identify the pattern of neurological disorders in a second biggest central hospital in Sudan. Review of the diagnosis of 170 patients, seen in the out patients neuro-clinic and the neurology ward from March 2010 to February 2011, was done. Patients who were in follow up by other neuro-clinics were excluded. The male to female ratio was 1:1 Patients who were 20-60 years old comprised 54%.About 50% of patients live in Omdurman city. Motor symptoms were the most common presenting symptoms forming 64.1% followed by cranial nerves symptoms 27.6%. Stroke was the commonest encountered diagnosis seen in 20.7%, followed by epilepsy in 16.6%, headache in 9.6%, movement disorders in 7.7%, peripheral neuropathy in 3.6%, demylination in 1.8%, cerebral venous sinus thrombosis [CVST] 1.8% and tumours in 1.2% patients. Stroke was more common in patients from East Sudan and Epilepsy was more common in patients from West Sudan. Vascular and degenerative changes were the commonest abnormalities seen in imaging studies. Demyelination and neoplasms were more common in females. Stroke, epilepsy and headache were the commonest neurological disorders met in Omdurman Teaching Hospital

Sudanese medical students and scientific research

Most of developing countries face problems in assessment of their public health practices. Gain of this knowledge is orchestrated by research. Medical students can play an essential role in improving public database. to explore knowledge, attitude and skills of medical students in the Faculty of Medicine and Health Sciences [FMHS], Omdurman Islamic University [OIU] towards research. This is a descriptive, analytical, cross-sectional, institution-based study. A total of 442 students, equally from each batch participated in the study. Equal numbers of male and female were considered to eliminate gender and seniority bias. Structured pretested questionnaire was used for data collection. Data collected were fed to Statistical Package for Social Sciences [SPSS] version 15. Means, standard deviation and correlations were done where appropriate. Statistical significance was taken at P=0.05.The mean knowledge score was 37% and attitude was positive in 77.1% of the students. Only 18.3% had attended research methodology workshop. The rate of internet navigation is directly proportional to the social class. Only 14.7% knew the engines used for finding medical literature. The low knowledge score is due to lack of application of research in the academic curriculum; however, the students have a fairly positive attitude. The knowledge is expected to improve with the intended policy to include practical research in the curriculum

Audit of ERCP at Ibn Sina Hospital from 2009-2010

Surgeons are expected to deal with expect some failure of ERCP in extraction of missed CBD stones. Re-do surgery is difficult; however surgeons have to stand for it. To audit the outcome of ERCP in extraction of CBD stone for patients referred to Ibn Sina Teaching Hospital. This is prospective, hospital based study; carried in the period from January 2009 to June 2010 in Ibn Sina Teaching Hospital .A total of 119 patients referred for ERCP extraction of CBD stones were studied. Male to female ratio was 1:5. The mean age [ +/- SD] is 55.4 [ +/- 17.57]. Post cholecystectomy missed stones were 7[6%], post CDB exploration retained stones were 4[3.4%] and re-do ERCP was done in 9[7.6%] patients. Failure of stone extraction occurred in 10[25%] cases due to failure of cannulation while another 10[25%] cases had multiple impacted stones and nine [22.2%] had too big stone to be extracted. In addition, five [12.5%] cases had CBD stricture, and the procedure was not completed because of bleeding in two cases and impaction of the dormia basket in two [5%] cases. The success of redo ERCP is seven out of nine cases. Complication occurred in seven [5.88%] patients. These were bleeding in two [1.68%], cholangitis in one [0.84%] CBD and retro-peritoneal duodenal perforations in two [1.68%] and retained dormia basket in two [1.68%] cases. The mortality rate was one [0.8%] patient. ERCP, at Ibn Sina Hospital, has success rate in stone extraction in 79[66.4%] and complication rate in seven [5.88%] patients. About one third of cases attending ERCP for stone extraction were referred back for open exploration of CBD

Epidemic of Kaposi's sarcoma in the Nuba Mountain: fact or fiction

Kaposi's sarcoma [KS] is a complex neoplasm characterized by angio-proliferative multifocal tumors of the skin, mucosa and viscera. There are four different epidemiological forms of KS: classic [sporadic] [cKS], African [endemic], AIDS-associated [epidemic], and immunosupression-associated [iatrogenic]. In this paper we report for the first time types of Kaposi's sarcoma from the Nuba Mountains as seen in Dermatology Military Hospital. Clinical features and confirmative tests were done for six patients. Three, two and one cases were AIDS rated, endemic type and iatrogenic type of Kaposi's sarcoma respectively. We report a series of Kaposi's sarcoma in six Sudanese patients. Mean age 66.7 year, five of them were males and a female. The AIDS associated KS patients showed good response to management and are under follow-up on HAART. The endemic type cases have been improved with chemotherapy. The single case of iatrogenic KS could not be traced

Rockall score of the acute upper gastrointestinal bleeding patients the experience in Sudan

Innovation of scoring systems helps to rectify personal experience based on subjective evaluation of outcome of patient treatment. To predict the morbidity and mortality in patients presenting with acute upper gastrointestinal bleeding at Ibn-Sina Hospital using the Rockall score. Prospective hospital-based study conducted from June 2007 through December 2007 at the Ibn-Sina Hospital Bleeding Centre. Demographic, data of history and physical examination and results of laboratory investigations of 238 patients were collected and allotted a Rockall score, Child-Pugh class and fed to Statistical Package of Social Sciences [SPSS] to calculate means and find the levels of statistical differences and define the predicted and observed mortality rates. The mean [ +/- SD] age 44.6 [ +/- 15.31] range [8-85] years. There were 190 [79%] males. Patients with oesophageal varices, peptic ulcer, and upper GI tumours were 215 [90.3%], 18 [7.6%], and 5 [2.1%], respectively. The mean/predicted mortality was 3.8% while the actual observed mortality 3.8%. The mortality in cases of oesophageal varices was 8[3.4%], while that of bleeding peptic ulcers was one [0.4%]. Rockall score is feasible, accurate, effective system for predicting outcome in patients with upper GI bleeding. The risk factor for mortality are Rockall score>3, age>70 and rebleeding

Physician burnout syndrome

The medical profession is the second largest official profession in Sudan. The fast spread of information technology in the eve of the second millennium has created an atmosphere of great expectations, that medical doctors should be updated, skillful, enthusiastic, kind, treat patients, train registrars teach medical students and develop high moral and ethical attitudes. The purpose of this paper is to high light the Physician Burnout Syndrome and its relation to unintentional medical errors and society lack of satisfaction. Brief literature review and observations from the current atmosphere of medical practice in Sudan. Early detection is the responsibility of the administration and medical colleagues to save victims of the Physician Burnout Syndrome and prevent medical errors, unintentional laxity, disregard and/or malpractice

Gastrointestinal fistula: audit of management in a remote hospital

The management of gastrointestinal fistula continues to present considerable challenge to the surgeon in general and gastrointestinal surgeon in particular. To audit the management and report the outcome of the gastrointestinal fistula in a remote hospital. Eldamazeen Hospital is a regional hospital in the Blue Nile state, south east of Sudan. Retrospective analysis of demographic and clinical data of patients with gastrointestinal fistula admitted to the surgical department in the period from Feb 2003 through Feb 2008. 10 [83.3%] patients had high out-put fistula. Two fistulas were complex and 10 were simple. The small intestine was the commonest site of fistula followed by the large bowel. The commonest causes of the gastrointestinal fistula are emergency operations for stab wounds, laparotomy and caesarean section. The overall mortality rate is 2 [16, 7%] patients mainly due to inter-abdominal abscesses. Conservative treatment with nutritional support is the corner stay for successful treatment. However, early surgical management of septic foci should be considered

Implementation of task-based and problem-based pharmacotherapy course for pre-clinical medical students

Pharmacology, like other basic science disciplines, is still taught didactically in many medical schools. Increasing number of drugs, changes on general principles of mechanisms of drug action and more information on properties of drugs require innovative approaches to undergraduate education. Research in medical and pharmaceutical education is increasingly utilizing a variety of innovative teaching methods to ultimately improve retention of knowledge. This paper describes implementation of new task-based and problem-based pharmacotherapy course for 3rd year pre-clinical medical students at Faculty of Medicine and Health Sciences, Omdurman Islamic University

modified apache ii score for predicting mortality of variceal bleeding

Prediction of outcome of based on personal experience is subjective. There is a need for a method of prediction to suit our current state of practice. To evaluate a modified APACHE II system in predicting mortality in acute variceal bleeding. Prospective study conducted from June 2005 through September 2006 in the Ibn Sina Hospital Bleeding Centre ICU. Clinical and laboratory data for 102 patients were allotted a modified APACHE II score, a child-Pugh class and fed to SPSS to calculate predicted mortality. The mean [ +/- SD] age 49.2[ +/- 16.1] years. Male were 79[77.5%]. Patients with liver cirrhosis and periportal fibrosis were 75 [73.5%] and 27 [26.5%]] respectively. The mean predicted mortality was 22.8% while the actual mortality was 26.5% [27] patients. The mean modified APACHE II score among the deceased group was 19.04. Rate of deaths among liver cirrhosis patients was 12 [44.4%] with mean predicted mortality of 27.3%. Deaths among periportal fibrosis occur at mean modified APACHE II score 17.7 and mean predicted mortality of 20%. Seventeen patients had ICU stay >/= 4 days. Ten out of them died [58.8%]. Modified APACHE II score is effective in predicting outcome of patients with variceal bleeding. Score of >/= 15 points and long ICU stay are associated with high mortality

Acute cholecystitis in paediatric patients in Khartoum, Sudan

Acute cholecystitis in children is a rare presentation, especially acalcular type. Many cases of acute cholecystitis in paediatrics were reported in western literatures, but few reports were published from tropical countries. The objectives of this study are to reflect on frequency of acute cholecystitis, its risk factors, diagnostic methods and outcome in children. A prospective data collection of five [2.5%] patients, one female and four males, with acute cholecystitis, collected among 200 paediatric patients presented with acute surgical abdomen over six months, between August 2006 through January 2007 in Khartoum teaching hospital plus another three elective cases [one male and 2 females] collected from private centre over two years. Five [2.5%] patients had acute cholecystitis and three elective cases. Five boys and three girls. Their ages ranged from 6 to 11 years. They were five cases of calcular cholecystitis. Thickened gallbladder wall, non shadowing echogenic materials or sludge in four patients, and pericholecystic fluid collection in two patients. No identifiable causes were found in four patients, one patient with acalcular cholecystitis discovered to have Salmonella infection and 2 children with sickle cell disease. Acute cholecystitis in pediatric is not common. High index of suspicion is required for correct diagnosis

Iatrogenic major bile duct injuries injury

Through out the last decade we used to receive at ibn Sina Hospital a steady rate of referrals of iatrogenic major bile duct injuries [IMBDIs] which had been inflicted mainly during open cholecystectomy[1]. This was the real motivation for designing this review to reflect on the situation in the international literature. The WHO in 1948 defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity". Towards the eve of the last century globalization had led the way towards best quality in all professions with special reference to quality of life[3, 4]. Infection and bleeding are the recognized complications of surgery. However, IMBDI remains the most disastrous complication that leads to major morbidities and sometimes mortality. Bile duct injury was estimated as 0.1-0.3% and 0.4- 0.6% in open and laparoscopic cholecystectomy respectively" 6. 7. 8. 9, This rate may reach 1.4%10.11 with mortality as high as II% 12. The best management ought to be based on the best evidence, personal expertise and available facilities. Hence, we started collecting the relevant data for this review

Peutz -jegher's syndrome: three case reports

Peutz-Jegher syndrome [PIS] is an autosomal dominant disease characterized by hamartomatous intestinal polyps associated with muco-cutaneous melanocytic macules. STK11 /LBK1 is proved to be the responsible gene for inheritanatcel[1] Patients with PIS have 15 fold increase risk of developing malignancy[2], which could be gastrointestinal as oesophageal, gastric, pancreatic and colonic or non intestinal cancer such as lung, breast, ovary and testicular cancer. Here we reported three patients presented to the Gastroenterology Department at Ibn Sina Hospital Sudan over the last ten years

Appendicular mass revisited

Management and timing of surgery for appendicular mass is controversial. To audit the management of appendicular mass in Khartoum Teaching Hospital. Analysis of demographic and clinical data of 280 patients in the period Jan 2000 through Dec 2006. Out of 280 patients 104 [37.5%] were in the third decade. 204 [72.9%] had pain for more than five days and 136 [48.6%] had temperature >37.5°C. Conservative management was successful in 156 [55.7%] patients. 25 [8.9%] patients had emergency surgery. 28 [10%] patients came for follow up but refused surgery. Mucocele of the appendix and carcinoma of the caecum were found each in one patient. Emergency surgery was difficult in eight patients with failure to remove the appendix in one of them and faecal fistula developed in two. The conservative method is safe. However, cancer caecum may be missed. In contrast emergency surgery led to faecal fistula in two patients